Oversight of the 12 Cities Project: How
Coordination and Integration are
Changing How We Fight HIV/AIDS
Vera Yakovchenko, MPH, HHS/OHAIDP
Stewart Landers, JD, MCP, John Snow, Inc.
RW 2012 Grantee Meeting
November 27, 2012
Disclosures
This continuing education activity is managed and
accredited by Professional Education Service Group. The
information presenting in this activity represents the
opinion of the faculty. Neither PESG, nor any accrediting
organization endorses any commercial products displayed
or mentioned in conjunction with this activity.
Commercial support was not received for this activity.
Disclosures
 Vera Yakovchenko, MPH has no financial
interest or relationships to disclose
 Stewart Landers, JD, MCP has no financial
interest or relationships to disclose
 CME Staff Disclosures
– Professional Education Services Group staff have no
financial interest or relationships to disclose
Learning Objectives
 To enhance grantees’ understanding of how the
12 Cities Project relates to and differs from
ECHPP and the NHAS
 To disseminate successful efforts at coordination
and integration that have been implemented in
the 12 cities
 To discuss and brainstorm how to address
challenges that arise from increased
coordination
Obtaining CME/CE Credit
If you would like to receive continuing
education credit for this activity, please
visit:
http://www.pesgce.com/RyanWhite2012
Overview of Evaluation
 Undertaken by the Office of the Assistant
Secretary for Health (OASH), Office of
HIV/AIDS and Infectious Disease Policy
(OHAIDP), U.S. Department of Health and
Human Services (HHS)
 John Snow, Inc. (JSI) contracted by OHAIDP to
conduct evaluation and prepare report
 Conducted August 2011 - July 2012
What is the 12 Cities Project
(12 CP)?
Developed by HHS to address the fourth goal of
the National HIV/AIDS Strategy:
Achieve a more coordinated national response
to the HIV epidemic in the United States
“…an effort to support comprehensive HIV/AIDS
planning and cross-agency response in 12
communities hit hard by HIV/AIDS…”
- 2011 HHS Operational Plan: Achieving the Vision of the NHAS
Federal Partners
Figure 2: 12 Cities Project Federal Partners
The 12 Cities*
Representing 44% of the AIDS cases in the U.S.:
• New York City, NY
• Philadelphia, PA
• Los Angeles, CA
• Houston, TX
• Washington, DC
• San Francisco, CA
• Chicago, IL
• Baltimore, MD
• Atlanta, GA
• Dallas, TX
• Miami, FL
• San Juan, PR
* By AIDS prevalence highest to lowest
12 CP/NHAS Principles
 Concentrate resources where epidemic most
severe
 Coordinate Federal resources and actions across
categorical program lines
 Scale up effective HIV prevention and treatment
strategies
Selected 12 CP Activities
 Provide a complete mapping of Federally funded
HIV/AIDS resources in each jurisdiction
 Identify opportunities to harmonize and streamline
Federal reporting and other grant requirements
 Identify and address local barriers to coordination
across HHS grantees
 Develop cross-agency strategies for addressing gaps in
coverage and scale of necessary HIV prevention, care,
and treatment services
 Actively promote opportunities to blend services and
funding streams across Federal programs
Purposes of the Evaluation
 Answer these two questions:
 Has the 12 CP helped achieve a more coordinated national
response to the HIV epidemic in the U.S.?
 Did local jurisdictions undertake coordination,
collaboration, and integration (CCI) efforts of their own?
 Make recommendations to improve ongoing
and future efforts
 Identify and share successes
Definition of CCI
Collaboration
Coordination
Integration
A more
comprehensive
and seamless
approach to
addressing the
HIV epidemic
Primary Evaluation Question
What has been the impact of the 12 CP on
CCI among Federally-funded HIV programs
at the local level?
Five domains:
•
•
•
•
•
planning
resources
programs/services
communication
data systems
Qualitative Approach
Qualitative
Focus
General Definition
Meaning
Participant perspectives and how
they understand phenomena being
studied
Local partners understanding of
the purpose and role of 12 CP
Context
Situation of participants and how
events, actions, and meanings are
shaped by local circumstances
Local factors that have affected
implementation of 12 CP in each
jurisdiction
How events occurred or actions
were undertaken, and how they led
to particular outcomes
Activities undertaken by local
partners related to 12 CP and
purpose or goals of those actions
How X plays a role in causing Y,
and the process that connects X
and Y
Potential impacts of 12 CP and
Federal activities on jurisdictions
Processes
Explanations
Application to 12 CP
Evaluation
Data Collection Steps
Materials
Review
Federal
Context
Local
Experiences
Federal Agency Findings
 Greater understanding of 12 CP among
traditional partners (CDC, HRSA)
 Specific activities by each agency
• MAI-TCE, CFAR grants, BPHC training, IHS add-ons
 12 CP Impact:
• Facilitated communication within and across agencies
• Supported use of resources for the 12 jurisdictions
• Emphasized reducing reporting burden while
measuring systems-level changes and outcomes
Discussions with the 12 Cities
 Assessed the 12 CP overall, not local performance
 Explored:
• Understanding of goals and purpose of the 12 CP
• Progress toward increased CCI of Federally funded HIV/AIDS
prevention, treatment, care services locally
• Groups, organizations, or individuals involved in efforts
to increase CCI
• Factors that helped or hindered efforts to improve
or increase CCI
• Technical assistance received or needed
• Monitoring and measurement of CCI activities
JSI identified
7 themes
Understanding of the 12 CP and its goals varied
across and within jurisdictions
Understanding of the 12 CP varied by role
and position of the stakeholder
12 CP was perceived primarily as a
Federal initiative
12 CP has encouraged new partnerships
Ongoing communication between Federal and local
partners is necessary to achieve 12 CP goals
Open communication between local and
Federal partners is welcome and
appreciated
Involvement in local CCI efforts has
varied across Federal partners
Many Federal programs can be engaged
that have not been
Increased coordination of HIV prevention and care
planning has occurred in response
to a range of initiatives, including 12 CP
 Community planning activities  a continuum of
CCI efforts to bridge care and prevention
 New partners have joined community planning
efforts.
 Data are driving planning efforts in new ways.
 Access to information about all HIV resources
and services in the jurisdictions can enhance
community planning.
 Lack of Federal guidance can impede planning.
12 CP has reinforced and provided a rationale for
jurisdictional progress toward integration of
HIV care and prevention services
 Some HIV services enhanced and
integrated
• HIV testing
• Linkage to care
• Prevention with positives
 Perceived need for CBOs to merge with
clinical providers, concern about impact
of these changes
Funding mechanisms have encouraged CCI and
new partnerships locally, and can be used more
effectively to achieve goals of the NHAS and 12 CP.
 Federal guidance for requests for
proposals (RFPs), FOAs, and grants are
significant tools for communicating 12
CP priorities and encouraging CCI.
 Federal funding reporting requirements
on service provision a barrier to local
CCI.
 Local funding initiatives can guide CCI
and new service delivery models.
Data are driving decision making in new ways,
but data collection and reporting remain
significant challenges.
 Jurisdictions using surveillance data and
triangulating data to plan and target resources
 Jurisdictions are coordinating and integrating
data across systems
 Federal HIV prevention and care data systems
need to be better coordinated
 Lack of consistent definitions of terms and
eligibility criteria across Federal funders
impedes CCI efforts
CCI is resource intensive, requiring time, staff,
funding, communication, and support.
CCI was already in place
CCI can be challenging
• Resource strain, role of ACA, Ryan White
reauthorization
Trust is an important facilitator of
CCI
Summary of CCI Progress
 Integrated HIV planning
 New Federal and local partner participation in local
activities
 Increased communication between Federal and local
partners
 Increased access to some data (e.g., local HIV
resources)
 Coordination and integration of some HIV prevention
and care services
 Increased use of data to guide planning and decision
making
Ongoing Facilitators
 HHS leadership
 Local leadership and structures that support
coordination and de-emphasize competition
 Prior CCI-related initiatives (e.g., PCSI, ECHPP,
EIIHA)
 New and existing local relationships
 Funding to support CCI
Ongoing Facilitators
Development of trust through small successes
A history of working together
Data sharing to effectively target services
Integrated data systems for monitoring and
reporting
 Access to information on HIV resources in local
jurisdiction




Ongoing Barriers
 Lack of clarity about 12 CP and local role
 Variable involvement of Federal and local
partners
 Lack of coordination across Federal funding
streams
 Political or administrative “boundaries”
 National recession and state budget cuts
 Time, resource constraints, and competing
priorities
Ongoing Barriers
 Disparate Federal and local reporting
requirements
 Different Federal definitions of terms and
criteria
 Incompatible data systems
 Mastering a large, complicated system
Recommendations
 Make any new programs “user friendly” and
adaptable to the needs of the jurisdictions.
 More support is needed for CBOs that are
exploring efforts to integrate clinical services or
to merge with clinical providers.
 HHS should work with its agencies to identify a
common guidance or framework for HIV
prevention and care planning.
Recommendations
 A consistent practice of notifying state and local
jurisdictions of directly funded services and
programs
 HHS should develop and implement a small
number of common indicators
 “HIV regional planning areas” that would act to
clarify and consolidate jurisdictional issues with
respect to Federal funding streams
Questions for HHS
 What role could programmatic guidance and
benchmarks have in assisting to clarify goals related to
future CCI efforts?
 How can activities at the Federal level best be viewed
through the lens of the needs of local (and state)
jurisdictions?
 How can information about Federally funded activities at
the state and local level best be shared? How local/state
jurisdictions use that information to improve CCI?
Questions for Local
Jurisdictions
 To what extent have localities coordinated or integrated their
Federal funding steams in response to the HIV/AIDS
epidemic?
 What are the major breakdown points and greatest areas of
fragmentation?
 What methods have been most effective to effect this
coordination i.e. a staff person with responsibility, crossprogram teams, development of logic model, etc.?
 How can local/state jurisdictions communicate clearly with
Federal liaisons (POs, regional reps, etc.) regarding further
actions required to support CCI at the local level?
Questions for Everyone
 How do we better bridge the role and function of
the Federal government, state and local health
departments and CBOs?
 What is the evolving role of CBOs and how
should they be redefined?
 What steps can be taken to further coordinate
these funding streams that would assist us in
achieve both locally set priorities as well as the
goals of the NHAS?
Acknowledgements
 Dr. Ron Valdiserri, Vera Yakovchenko,
Dr. Andrew Forsyth, and other OHAIDP staff
 Representatives from Federal partner agencies
(CDC, CMS, HRSA, IHS, NIH, USPHS, and
SAMHSA)
Acknowledgements
 ECHPP contacts in each city and other individuals provided information,
assisted with meeting logistics, and/or participated in meetings. The
following were the initial contacts and for each of the 12 Cities:
Blayne Cutler
Donato Clarke
Dara Geckeler
New York City, NY
Atlanta, GA
San Francisco, CA
Jacqueline
Rurangirwa
Marlene Lalota
Heather Hauck
Miami, FL
Baltimore, MD
Nestor Rocha
Coleman Terrell
Ann Robbins
Washington, DC
Philadelphia, PA
Dallas, TX
David Amarathithada
Marlene McNeese-Ward
Margaret Wolfe
Chicago, IL
Houston, TX
San Juan, PR
Los Angeles, CA
Coordinating HIV
Prevention & Care in NYC
Graham Harriman, MA, LPC
Interim Director Care and Treatment
Bureau of HIV/AIDS Prevention and Control
How It All Fits Together…
NHAS: (2011-2015)
12 Cities Project: (HHS)
CDC
SAMHSA
NIH
HRSA
ECHPP Phase I in NYC (2010-2011)
• Situational Analysis (3-4 months)
• Assessment of current NYC landscape
• Describe activities underway in each of 24 CDC interventions
• Comprehensive review of HIV prevention in NYC:
• Development of goals and objectives for project period.
• Preliminary modeling results: maximal infections averted
•
•
•
•
•
•
Maximize HIV testing and linkage to care
Condoms, particularly high risk HIV (+) persons
Social marketing to HIV (+) persons
Community level interventions
Screening/treatment of STDS, SU/MH for HIV+
Partner services
Key Shifts Accelerated by ECHPP/NHAS
ECHPP Phase II in NYC (2011-2013)
• Further Scale Up of ‘Coefficients’ in TLC Strategy:
• Testing
• Enhance/Expand Jurisdictional HIV Testing
• Shift in NYS Testing Law (September 2010)
• Rebid of testing portfolio, use of MPAs (2011)
• Linkage to Care
• Contractual incentives for linkage and navigation (2011)
• Required ARTAS training (2011)
• Treatment
• Medical case management for engagement/retention
(2009)
• Early ART recommendation (December 2011)
Key Shifts Accelerated by ECHPP/NHAS
ECHPP Phase II in NYC (2011-2013)
• Enhancing Prevention Among HIV (+) Persons
•
•
•
•
Clinic-based pilot of three PWP risk reduction models (2012)
Condom distribution to HIV (+) ‘universe’ (2011)
The Positive Life Workshop (September 2011)
Enhancement of PS for newly diagnosed and AHI cases
• Scale back low yield/high cost interventions
• EBIs for low prevalence populations (2012)
• Cofactor screening for low prevalence populations (2012)
• Deploy relevant structural interventions
• Ex: change in NYS testing law (2010)
• Early ART (December 2011)
Key Shifts Accelerated by ECHPP/NHAS
ECHPP Phase II in NYC (2011-2013)
• RFP Prevention Rebid
Service categories reflect ECHPP/NHAS goals:
1.
2.
3.
4.
5.
Integrated sexual/behavioral health for priority pops
System level/structural change
CLIs/community mobilization
Condoms for highly impacted populations
Demonstration projects in CDC core areas
 Biomedical/behavioral interventions that can reduce
HIV incidence
 Innovative HIV testing activities
 Enhanced linkage to and retention in care
 Advanced use of technology
Prevention & Care Collaboration:
Examples on the Ground
•
•
•
•
•
•
PWP Pilot
Condom Distribution to HIV Primary Care Universe
Expansion of PS to more newly diagnosed & AHI cases
Testing (Joint RFP-2011)
Data Alignment (E*Share; PCSI data analyses)
Training
• Development and Roll out of Positive Life Workshop
• Alignment of Training and Technical Assistance Programs
PCSI Grant
• $352,000 per year for 3 years to NYC DOHMH
• primarily planning/internal infrastructure grant to
streamline data analysis and services.
• Began Sept. 30, 2010 and ends September 30, 2013.
• Coordinated by the DOHMH Division of Disease
Control
• Opportunities for greater integration of services:
• Data cross-match between registries
• Partner services
• Curriculum integration: HIV, STDs, Hepatitis, TB
• Comprehensive sexual health module
• Joint HIV/Hep C testing modules
Impact of ECHPP and PCSI in NYC
• Enhanced collaboration within BHAPC units
• Alignment of research agenda
• between academic and public health entities
• Data integration between disease registries
• Mapping co-occuring diseases
• Real-time registry cross-matching
• Improved partner services delivery
• Lens to focus all stakeholders on NHAS targets
• ECHPP/PCSI has helped foster increased attention by
planning groups as well as clinical/non-clinical sites and
government agencies on achievement of NHAS targets.
Thank You
Graham Harriman
gharriman@health.nyc.gov
347.396.7418
DC 12 Cities Project
Michael Kharfen
Division Chief, Partnerships, Capacity Building & Community Outreach
Interim Division Chief, STD/TB Control
HIV/AIDS, Hepatitis, STD & TB Administration
District of Columbia Department of Health
Changing Public Health Environment
ACA
NHAS
12 Cities
ECHPP
PCSI
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
DC 12 Cities Project Overview
 Goal: Develop Integrated Behavioral Health Network for Focus
Population
 Persons living with HIV or High Risk of HIV with co-occuring conditions of
substance use disorder and/or serious persistent mental illness
 Objective 1: Integrate linkage and navigation support infrastructure
 Objective 2: Increase utilization of services
 Objective 3: Improve and expand provider network capacity to serve
individuals with multiple needs
 Objective 4: Create a mechanism for sharing information across systems
(HIE)
 Objective 5: Develop a sustainability plan
 Objective 6: Develop and implement an integrated prevention risk
management plan
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
DC 12 Cities Project Overview
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Provider Crosswalk
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Objective 1: Integrate Linkage and
Navigation Support Infrastructure
 Introduce HIV testing/screening at Substance Use and




Mental Health intake and assessment sites
Standardize mental health screening process
Standardize substance abuse screening process
Develop connection pathways to service system
Improve cross‐agency coordination and collaboration
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
“No Wrong Door” Approach
ARC
UCC
HIV
Government of the District of Columbia
GAIN
Screen
MH
DX
MH
HIV
Test
HIV
DX
HIV
GAIN
Screen
SA
DX
SA
HIV
Test
HIV
DX
HIV
SA
DX
SA
MH
DX
MH
GAIN
Screen
Department of Health
Coordinated Care
HIV/AIDS, Hepatitis, STD, and TB Administration
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
STD Clinic Pilot
 2 month demonstration GAIN short screener
Total Surveys
1,248
MH Referrals
71
SA Referrals
31
Pending Follow-up
37
Refused Surveys
36
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Conclusion
 Integration is not easy
 Inter/Intra agency collaboration
 Separate service networks
 Data systems and data restrictions
 Different points of entry
 Opportunities
 Coordinated patient care
 Better health outcomes
 Leveraging resources
 Time and Persistence
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Thank You
Michael Kharfen
(202) 671-4809
Michael.Kharfen@dc.gov
Government of the District of Columbia
Department of Health
HIV/AIDS, Hepatitis, STD, and TB Administration
Collaboration, Coordination, and
Integration (CCI) in San Francisco
2012 Ryan White Grantee Meeting
November 27, 2012
Presentation developed by Tracey Packer, Acting Director of HIV Prevention
Presented by Bill Blum, LCSW, Director of HIV Health Services
San Francisco Department of Public Health
Coordination*
 to place or class in the same order, rank, division,
etc.
 to place or arrange in proper order or position.
 to combine in harmonious relation or action.
*Dictionary.com
Collaboration*
 to work, one with another; cooperate, as on a
literary work:
 creating a culture where agencies are naturally more
interconnected and their programs are better aligned.
 *Dictionary.com
Integration*
 an act or instance of combining into an integral whole.
 necessary to the completeness of the whole
 *Dictionary.com
CCI in San Francisco – some examples
 Collaboration: working with police, and other City
departments to explore eliminating condoms as evidence for sex
work.
 Coordination: syringe disposal in alley outside clinic, Minority
AIDS Initiative Targeted Capacity Expansion
 Integration: HIV Health Services (CARE funding) and HIV
Prevention joint meetings to coordinate treatment as prevention,
funding PWP as part of Centers of Excellence as well as
coordination and possible integration of the two planning councils
 CCI: Health Department reorganization/integration (PCSI)
Facilitating Factors of CCI
 Funding for CCI Efforts
 Required deliverables (ECHPP, PCSI)
 Achieving outcomes
 Attending to patient needs holistically
 Ability to address the social determinants of health
 Reduction of data burden (sharing and integrated systems)
Barriers to CCI:
 “If you think everyone’s in your business, it’s because
everyone’s in your business”
 “The only thing worse than them talking about you is them
not talking about you”
 Conflicting scopes
 Culture/communication
 Data requirements
 Decrease in funding
Lessons Learned
 CCI is an effort unto itself
 Focus on areas of commonality (populations)
 Practice humility and humor
 Take Risks around Change
 Develop a common language
 Understanding Change (communication)
Lesson #2: This is not new
•HIV testing
•Partner services
•STD prevention and treatment
•Addressing drivers and co-factors of HIV
•Linkage to medical
•Risk reduction activities
•Community mobilization efforts
HIV and STD
•Public information efforts
Prevention
•Condom distribution
•Syringe access
•PEP
•Core Surveillance
•Incidence Surveillance
•Medical Monitoring
•NHBS
•Vaccine studies
•PrEP research
•HIV drug resistance testing
Surveillance,
Evaluation
and Research
HIV Care and
Support
Services
Primary Care
and HIV
treatment
•Linkage to medical care
•Behavioral Health Services
•Home Health Service
•Non-medical case management
•Food Bank / Home-delivered meals
•Client Advocacy-related services
•Emergency financial assistance
•Legal services
•Housing services
•Oral health care
•Outreach services
•Engagement in care
•Treatment Adherence
•Medical Case management
•ADAP
•Community Health Care
•HIV specialty medical care
•Treatment Guidelines
•STD and TB
Source: Nieves-Rivera, 2010
Build and strengthen relationships
Health
departments
Federal and
state
agencies
Researchers
Capacitybuilding
providers
Clinical
providers
Communitybased
providers
Community
planning
groups
Our direction is clear:
 “If they [steps in the NHAS] are to have any impact,
individuals and groups all over the country will need to
follow the path described and produce a more coordinated,
collective response to HIV.”
 “With government at all levels doing its part, a committed
private sector, and leadership from people living with HIV
and affected communities, the US can dramatically reduce
HIV transmission and better support people living with HIV
and their families.”
 National HIV/AIDS Strategy, July 2010